| VAERS ID: |
935343 (history) |
| Form: |
Version 2.0 |
| Age: |
89.0 |
| Sex: |
Female |
| Location: |
Kansas |
| Vaccinated: | 2021-01-08 |
| Onset: | 2021-01-11 |
| Days after vaccination: | 3 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-11 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
- / UNK |
- / SYR |
Administered by: Senior Living Purchased by: ? Symptoms: Death SMQs:
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-11
Days after onset: 0
Permanent Disability? No
Recovered? No Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: Other Medications: Current Illness: Preexisting Conditions: This resident had covid a couple months ago. she had a bad heart and also dementia. I do not believe it was the vaccine that killed her. I was instructed by EMS to report because the date of vaccination was three days ago. Allergies: Diagnostic Lab Data: CDC Split Type:
Write-up: There were no adverse reactions. Resident Died, she had a history of issues with her health prior to the vaccine. |